Provider Demographics
NPI:1326316282
Name:RYAN, TERESA (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 HADDEN HALL PL
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-7270
Mailing Address - Country:US
Mailing Address - Phone:727-434-2265
Mailing Address - Fax:
Practice Address - Street 1:1708 HADDEN HALL PL
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-7270
Practice Address - Country:US
Practice Address - Phone:727-434-2265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-09-6641103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst